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Miscellaneous Letter to Editor DOI: 10.7860/JCDR/2018/36646.11818 Original Article

Postgraduate Education Association of Coronary Artery Case Series Diseases with ABO and Lewis Blood Group Phenotypes at a Tertiary Care Short Communication Transfusion Medicine Section Transfusion Teaching Hospital in Southern India

Anitha Madithadu1, Arun Rajendran2, Rajashekar Durgaprasad3, Sarella Jothibai4 ­ ABSTRACT Results: Blood group O was the most common (41.2%) blood Introduction: Since the discovery of blood group systems, group in the controls followed by blood group B (33.2%), A involvement of ABO system to was (21.9%), AB (3.7%). The prevalence of O group in the CAD suggested. Epidemiological data on the association of ABO and patients was almost similar to controls, but comparatively, the Lewis blood group with coronary artery disease from Southern frequency of Non O groups showed a mild increase in the CAD India was not available. patients; the frequency of AB groups in these patients was Aim: To assess the pattern and association of ABO and Lewis comparatively less than the controls. The prevalence of Le (a-b-) blood group phenotypes in confirmed Coronary Artery Disease phenotype has been observed to be 32.6%. We observed that (CAD) patients attending the tertiary care hospital in Southern 94.1% of cases were associated with risk factors like ‘Smoking’, India. ‘Hypertension’, ‘Diabetes mellitus’, ‘Dyslipidemia’. Materials and Methods: The present study was a single centric Conclusion: The present study failed to show a significant case control analytic study where 187 clinically confirmed association of ABO blood group with CAD but showed a CAD cases were compared with age and gender matched significant association of ABO group with risk factors like 187 healthy controls. ABO grouping and Lewis antigen typing hypertension, dyslipidemia and smoking. It also showed a were determined to know the association with CAD and its risk significant association of Le (a-b-) phenotype with CAD and with factors. Statistical analysis was done using SPSS version 20.0 risk factors like diabetes mellitus, dyslipidemia and smoking. and by computing categorical variables in percentage.

Keywords: ABO blood group system, Lewis negative phenotype, Ischaemic disease

INTRODUCTION negative phenotype than among persons with Lewis positive Blood group antigens of the ABO and Lewis systems are not only phenotype [11]. Lewis (a-b-) blood group has been reported to be associated with hypercholesterolemia, diabetes mellitus expressed on the Red Blood Cell (RBC) membrane but are also and insulin resistance conditions which are considered to be expressed on the surface of the platelets, the vascular endothelium, high risk factors for CAD [12]. The association between the sensory neurons, and epithelium [1]. Lewis (Le) antigens are found Lewis genotype with subclinical carotid atherosclerosis was primarily in the secretions and the plasma and are adsorbed onto studied by Cakir B et al., who reported a statistically non the RBC membrane [2]. significant association between Lewis genotype and subclinical Studies report that blood Group A individuals are more atherosclerosis [13]. susceptible to cardiovascular diseases [3]. The major one was In view of the above varying reports, we have planned to undertake the Framingham study which reported that ‘A’ phenotype people the present study to assess the association of ABO and Lewis are more susceptible for CAD [4]. Wazirali H et al., suggested phenotypes in CAD patients attending the tertiary care hospital in that blood group A increases the risk of CAD independent of Southern India. conventional risk factors [5]. Some Indian studies also reported that the incidence of CAD in blood Group A Bengalese of North MATERIALS AND METHODS Bengal is higher compared to other blood groups [6]. A meta The present study was a single centric case-control analytical study conducted in the Department of Transfusion Medicine, Sri analysis report by Chen Z et al., comprising 17 studies showed Venkateswara Institute of Medical Sciences, Tirupati, Andhra that the risk of CAD was slightly higher in blood group A and Pradesh, India, from February 2015 to August 2016 after obtaining lower in blood group O [7]. In contrast, Garg P et al., reported approval from the Institutional Ethics Committee (IEC No: 443/09- a significant association between CAD and blood group B [8]. 03-2015). Inclusion criteria for the cases were patients between the Sahita P et al., from Gujarat, India, did not observe any association age group of 20-65 years with a diagnosis of CAD on the basis of between blood group and CAD after excluding patients with risk history of chest pain, electrocardiographic changes of ischaemia factors [9]. like ST elevation and associated risk factors like history of smoking, Patients with CAD were observed to have a significant, almost hypertension, diabetes mellitus and changes in the lipid profile. Only 2.5 times higher prevalence of Le (a-b-) phenotype compared those cases who underwent percutaneous transluminal coronary to controls [10]. Salomaa V et al., observed that carotid intima- angioplasty at the cardiology department of the institute and had media thickness was slightly higher among persons with Lewis angiographically positive result were included in the study. Exclusion

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criteria were those above 65 years of age, patients with other co- among cases and Le (a-b+) was the most prevalent phenotype morbid illness like malignancy, pregnant females, patients who were (66.9%) followed by Le (a-b-) (32.6%) in controls. There was a not willing to participate in the study. Age and Gender matched healthy blood donors who were eligible to donate blood as per the Lewis Cases Controls p-value inclusion and exclusion criteria of Drugs and Cosmetics Rules, 1945 Phenotype Number Percentage Number Percentage were taken as controls [14]. Le (a-b-) 115 61.5% 61 32.6% After obtaining written informed consent from each of the concerned Le (a-b+) 69 37.0% 125 66.9% subjects, 3 mL of blood in Ethylene Diamine Tetra Acetic acid Le (a+b-) 2 1.0% 1 0.5% 0.001* (EDTA) anticoagulant tube was collected separately from each CAD Le (a+b+) 1 0.5% 0 0 patient as well as from blood donors. Collection of blood samples Total 187 100% 187 100% repeatedly from the same subject were avoided by personally [Table/Fig-2]: Distribution of Lewis phenotype with CAD cases and controls. verifying the subject’s demographic profile such as full name, age, *Significant by chi-square test address, including hospital registration number and by collecting the blood sample in required quantity. significant association of Le (a-b-) phenotype with CAD patients. ABO blood grouping was performed according to department's The [Table/Fig-3] shows frequencies of various risk factors in CAD Standard Operational Procedures (SOP). Commercially available patients with ABO and Lewis blood groups. Smoking (81.2%) monoclonal blood group antisera (Tulip diagnostics Pvt. Ltd., Verna, followed by hypertension (39%) was the most common risk Goa, India) were used for forward grouping; for reverse grouping factor seen in CAD cases. The [Table/Fig-4] shows significant 5% pooled suspension of A, B and O cells were used which were association of hypertension as a risk factor for CAD patients with prepared according to SOP. blood group A (p-value=0.02) and no significant association with Lewis antigen typing was done by column agglutination technology Lewis blood groups. The [Table/Fig-5] shows that there was no method using monoclonal anti sera Lea, Leb (Ortho Clinical significant association of diabetes mellitus as a risk factor for Diagnostics, High Wycombe, UK) in a reverse diluent cassette CAD patients with ABO blood groups but shows significance (Ortho Clinical Diagnostics, High Wycombe, UK) as per the with Lewis phenotype Le (a-b-) and Le (a-b+). The [Table/Fig-6] manufacturer’s instructions. shows that there was a significant association of dyslipidemia as a risk factor for CAD patients with blood groups A and B and also STATISTICAL ANALYSIS with Lewis phenotype Le (a-b-) and Le (a-b+). The [Table/Fig-7] Statistical analysis was carried out using SPSS version 20.0. shows that there was a significant association of smoking as a Descriptive Statistics for the categorical variables were performed risk factor for CAD patients with blood group A, however, except by computing the frequencies (percentages) in each category. for Lewis phenotype Le (a-b+), it had significance with other three Comparison of categorical data between association of ABO and phenotypes. Multivariable logistic regression analysis showed that Lewis phenotypes in clinically confirmed CAD patients was done using chi-square test. Incidence was given in proportion with 95% Dys- Family Blood Hyperten- Diabetes Smoking Confidence Interval (CI). All statistical analysis was carried outat lipidemia ­History of groups sion n (%) n (%) n (%) 5% level of significance and p-value <0.05 was considered as n (%) CAD n (%) significant. To allow isolation of the effect of risk factors on CAD, O 28 (38.4) 22 (40) 20 (40) 66 (43.4) 14 (28) multivariable logistic regression models were used to estimate odds B 22 (30.1) 21 (38.2) 8 (16) 53 (34.9) 5 (10) ratios and CI for the association of ABO and Lewis phenotypes and A 22 (30.1) 11 (20) 22 (44) 26 (17.1) 31 (62) other risk factors relative to CAD. AB 1 (1.4) 1 (1.8) 0 (0) 7 (4.6) 0 (0) RESULTS Total (% among 73 (39.03%) 55 (29.41%) 50 (26.73%) 152 (81.28%) 50 (26.73%) During the study period, 187 patients with a diagnosis of CAD were 187) investigated to know the association of the CAD with ABO and Le (a-b-) 40 (54.8) 45 (81.8) 38 (76) 100 (65.8) 34 (68) Lewis blood group phenotypes along with age and gender matched Le (a-b+) 32 (43.8) 10 (18.2) 12 (24) 52 (34.2) 16 (32) control group of 187 healthy voluntary blood donors who attended Le (a+b-) 1 (1.4) 0 (0) 0 (0) 0 (0) 0 (0) present blood bank. Le (a+b+) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Both the CAD group and control group had 166 (89%) males and Total (% 21 (11%) females. The [Table/Fig-1] shows distribution of ABO among 73 (39.03%) 55 (29.41%) 50 (26.73%) 152 (81.28%) 50 (26.73%) blood groups among the CAD cases and controls. Group O was 187) the most prevalent followed by group B in both cases and controls [Table/Fig-3]: Frequency of various risk factors with ABO and Lewis blood groups and there was no significant association between CAD cases and in cases. controls (p-value=0.39). The [Table/Fig-2] shows distribution of Blood CAD cases with CAD cases without p-value Lewis phenotypes in CAD cases and controls. Le (a-b-) was the groups hypertension n (%) hypertension n (%) most prevalent phenotype (61.5%) followed by Le (a-b+) (37%) O 28 (38.4) 49 (43) 0.53

Blood Cases Control B 22 (30.1) 40 (35) 0.48 p-value* groups Number Percentage Number Percentage A 22 (30.1) 19 (17) 0.02* O 77 41.2% 80 42.8% AB 1 (1.4) 6 (5) 0.33 B 62 33.2% 58 31.0% Le (a-b-) 40 (54.8) 75 (65.8) 0.13 A 41 21.9% 35 18.7% 0.39 Le (a-b+) 32 (43.8) 37 (32.5) 0.11 AB 7 3.7% 14 7.5% Le (a+b-) 1 (1.4) 1 (0.8) 0.74 Total 187 100% 187 100% Le (a+b+) 0 (0) 1 (0.8) 0.42 [Table/Fig-1]: Distribution of blood groups in CAD cases and controls. [Table/Fig-4]: Association of hypertension between ABO and lewis blood groups. *by chi-square test *Significant by chi-square test

18 Journal of Clinical and Diagnostic Research. 2018 Jul, Vol-12(7): EC17-EC21 www.jcdr.net Anitha Madithadu et al., Coronary Artery Disease and ABO and Lewis Blood Group

CAD cases with CAD cases without in the controls, but comparatively, the frequency of non O groups’ Blood Total diabetes mellitus diabetes mellitus p-value groups n (%) i.e., A, B groups showed a mild increase in the CAD patients; n (%) n (%) whereas the frequency of blood group AB in these patients was O 22 (40) 55 (41.7) 77 (41) 0.83 comparatively less than the controls. B 21 (38.2) 41 (31) 62 (33) 0.34 In study, conducted at Punjab Institute of Cardiology, Lahore, by A 11 (20) 30 (22.7) 41 (22) 0.68 Sharif S et al., showed that the subjects with blood group A had AB 1 (1.8) 6 (4.5) 7 (4) 0.37 significantly higher risk of developing CAD as compared to other Le (a-b-) 45 (81.8) 70 (53) 115 (61.4) <0.001* blood groups [15]. Study done by Whincup PH et al., found that Le (a-b+) 10 (18.2) 59 (44.7) 69 (37) 0.001* the incidence of CAD was higher in blood group A individuals than with non-A [16]. Study by Garg P et al., reported that there was a Le (a+b-) 0 (0) 2 (1.5) 2 (1.1) 0.35 significant association between CAD and blood group B, where as Le (a+b+) 0 (0) 1 (0.8) 1 (0.5) 0.51 Banerjee S et al., indicated incidence of CAD highest in blood group [Table/Fig-5]: Association of diabetes mellitus between ABO and lewis blood groups. A [6,8]. *Significant by chi-square test The association of CAD with ABO blood group was supported by Blood CAD cases with CAD cases without evidence indicating that elevated Von-willebrand factor (vWF)-Factor Total n (%) p-value groups dyslipidemia n (%) dyslipidemia n (%) VIII levels are risk factors for CAD [15]. Blood group O individuals O 20 (40) 57 (42) 77 (41) 0.84 have approximately 25% lower plasma level of both factor VIII and B 08 (16) 54 (39) 62 (33) 0.003* vWF than other groups conferring an increased risk of thrombosis A 22 (44) 19 (13.9) 41 (22) <0.001* and CAD in non-O blood groups [17]. AB 0 (0) 7 (5.1) 7 (4) 0.10 Wu O et al., performed a systematic review and meta-analysis of Le (a-b-) 38 (76) 77 (56.2) 115 (61.4) 0.014* studies reporting the association of non-O blood groups with a variety of vascular disorders and observed a consistent relation Le (a-b+) 12 (24) 57 (41.5) 69 (37) 0.027* between non-O blood group and an increased CAD risk [18]. Le (a+b-) 0 (0) 2 (1.5) 2 (1.1) 0.39 He M et al., conducted a meta-analysis of data from the health Le (a+b+) 0 (0) 1 (0.8) 1 (0.5) 0.54 professionals and they concluded that individuals with non-O blood [Table/Fig-6]: Association of dyslipidemia between ABO and lewis blood groups. group had an 11% increased risk of developing CAD compared to *Significant by chi-square test that in O blood group individuals [19].

Blood CAD cases with CAD cases without In contrast to previous studies, Lutfullah AB et al., showed that Total n (%) p-value groups smoking n (%) smoking n (%) there was no direct correlation between ABO blood groups and O 66 (43.4) 11 (31.4) 77 (41) 0.19 major CAD risk factors [20]. Amirzadegan A et al., investigated a B 53 (34.9) 09 (25.7) 62 (33) 0.30 possible relationship of ABO blood groups with a large number of CAD patients. They observed that there was no relationship A 26 (17.1) 15 (42.9) 41 (22) 0.001* between ABO blood groups and development of CAD. Moreover, AB 7 (4.6) 0 (0) 7 (4) 0.19 the incidence of major risk factors was found equal in patients with Le (a-b-) 100 (65.8) 15 (42.8) 115 (61.4) 0.01* different blood groups [21]. Present study also does not show a Le (a-b+) 52 (34.2) 17 (48.6) 69 (37) 0.11 statistically significant association with ABO blood groups. These variations could be a result of biological variations or could be Le (a+b-) 0 (0) 2 (5.7) 2 (1.1) 0.003* because of small sample size. A much larger study population may Le (a+b+) 0 (0) 1 (2.9) 1 (0.5) 0.03* fully elucidate these findings. [Table/Fig-7]: Association of smoking between ABO and lewis blood groups. *Significant by chi-square test In the present study, we observed that 94.1% of cases were associated with risk factors like smoking, hypertension, diabetes Variables Odds Ratio (95% CI) p-value mellitus, dyslipidemia. Sharif S et al., showed the overall prevalence of hypertension was comparatively more with 58.5% and diabetes in ABO blood group 0.16 (0.09-0.20) 0.713 53.5% [15]. In the present study group of 187 patients, 73 (39.0%) Lewis phenotype 1.71 (1.50-1.89) <0.001* had hypertension with a significant association with blood group A Hypertension 1.51 (1.26-1.87) <0.001* and 55 (29.4%) had associated Type II diabetes mellitus, however it Diabetes 1.34 (1.11-1.72) <0.001* did not show any significant association with ABO Blood groups. Dyslipidemia 1.50 (1.23-1.96) <0.001* Sayed EL and Amin HK, showed that hypertension was more Smoking 1.48 (1.02-1.76) <0.001* common in blood group B followed by Blood group A [22]. They [Table/Fig-8]: Multivariable logistic regression analysis for predicting risk factors observed that blood group O is protective against hypertension for CAD. and blood group A and B is protective against the diabetes, and *significant by Multivariable Logistic Regression Analysis hyperlipidemia. Chandra T and Gupta A, showed that blood group B persons were more susceptible to hypertension [23]. In contrast Lewis phenotype was independently associated with an increased to above studies, in the present study, hypertension was seen more risk of CAD (Odds ratio: 1.71; 95% CI: 1.50-1.89) as shown in in blood group O (38.4%). [Table/Fig-8]. Blood Group A has been reported to show high levels of Serum DISCUSSION Total cholesterol (TC) and Low Density Lipoproteins (LDL). Several The present objective was to study the pattern and association studies showed high TC, Triglycerides (TG), LDL, and lower High of patient’s ABO and Lewis blood group phenotypes in clinically Density Lipoproteins (HDL) in blood groups A and B while groups confirmed CAD patients. In present study, Blood group O was the O and finally AB showed low levels of TC, TG, and LDL [24]. The most common (41.2%) blood group in the controls followed by present study showed a significant association with A and B blood 33.2% group B, 21.9% group A, 3.7% group AB. The prevalence of groups. Smoking was seen in 54% in a study done by Sharif S et al., blood group O in the CAD patients was almost similar to that seen where as in present study, it was seen in 81.2% [15].

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Epidemiological studies have suggested that the Lewis (a-b-) Venkateswara Institute of Medical Sciences, Tirupati for the partial phenotype was an independent predictor of coronary heart funding of the study. disease [25]. Mechanisms underlying this association were not established. The Lewis negative phenotype is fairly common. REFERENCES Its prevalence in Caucasians was approximately 10% and [1] Eastlund T. The histo-blood group ABO system and tissue transplantation. considerably higher in black individuals [26,27]. In the present Transfusion. 1998;38: 975-88. [2] Sneath JS, Sneath PHA. Transformation of the Lewis group of human red cells. study, the prevalence of Le (a-b-) phenotype has been observed to Nature. 1955;176:172. be 61.5% whereas a report from Dhaka has shown its prevalence [3] Platt D, Muhlberg W, Kiehl L, Schmitt-Ruth R. ABO blood groups as 49.2% [28]. Chaudhury R and Shukla JS, observed that there system, age, sex, risk factor and cardiac infarction. 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PARTICULARS OF CONTRIBUTORS: 1. Senior Resident, Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India. 2. Associate Professor, Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India. 3. Professor and Head, Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India. 4. Ex Professor and Head, Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Arun Rajendran, Associate Professor, Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India. Date of Submission: Apr 06, 2018 E-mail: [email protected] Date of Peer Review: Apr 28, 2018 Date of Acceptance: May 30, 2018 Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Jul 01, 2018

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